LaparoEndoscopic Single Site Orchidopexy for Intra-Abdominal Testes in the Pediatric Population with a Multichannel Single Port and Flexible Tip Laparoscope

Introduction

Traditional laparoscopic orchidopexy (LO) has been shown to be highly effective for intra-abdominal testes. ¹ As technology improves, we evolve in our surgical practice to optimize patient experience and outcomes. Minimally invasive surgery (MIS) has been rapidly changing. LaparoEndoscopic Single Site (LESS) surgery has been performed as another option for MIS. In the pediatric population, there are limited reports of LESS urological procedures. ^{2 –7} These procedures should provide the same high quality outcomes as standard laparoscopic procedures, if they are to be performed. We assess outcomes of our early experience with LESS orchidopexy in the pediatric population utilizing a commercially available multi-channel single port (MCSP) device and a flexible tip laparoscope (FTL).

Patients and Methods

A retrospective cohort study was performed of children who underwent LESS orchidopexy by a single surgeon at a pediatric institution. Patient demographics, intraoperative details, operative time, complications, and surgical outcomes were reviewed. Patients with a nonpalpable testis were scheduled for laparoscopy. All procedures were video recorded during laparoscopy.

Open access was obtained to the abdomen with a midline umbilical incision. A 5 mm trocar was initially used to perform a diagnostic laparoscopy and confirm the presence of an undescended testis. A 5 mm FTL (Olympus EndoEYE^™) was utilized. A MCSP (Olympus TriPort^™) was introduced into the abdomen. The ipsilateral surgical side of the operative table was tilted up to facilitate exposure. Standard 3 mm and 5 mm instruments were used for dissection and mobilization of the testes. A curved scissor and Maryland dissector were used. The assistant actively flexes the tip of the laparoscope to optimize visualization and positions the shaft of the laparoscope to minimize external collisions of the surgeon's instruments and the laparoscope. The peritoneum was mobilized off of the gonadal vessels. A peritoneal incision medial to the vas deferens was made. The gubernaculum was routinely pulled into the abdomen and divided. The dissection was extended proximally to optimize mobilization for a tension free orchidopexy. The obliterated umbilical ligament was divided on an individual basis to shorten the course of the vessels, during delivery to the scrotum. For a primary Fowler-Stephens (FS) orchidopexy, a sealing energy device was used to control and divide the gonadal vessels. A wide margin of peritoneum was preserved on each side of the vas deferens for FS procedures. No additional trocars were used for any of the procedures.

An ipsilateral scrotal incision was made, and a dartos pouch was created. A clamp was passed through the scrotal incision into the abdomen. The gubernaculum was clamped, and the testis was delivered into the dartos pouch. Additional dissection was performed if any significant tension of the vessels was noted. After the dissection was completed, the MSCP was removed. The umbilicus was reconstructed with interrupted 3-0 and 5-0 absorbable suture. The testis was secured within the dartos pouch utilizing either internal or external fixation. External fixation included a polypropylene button, which was removed at the first follow-up visit.

All procedures were performed on an outpatient basis without postoperative narcotic analgesia. Postoperative pain was treated with Acetaminophen every 6 hours and Ibuprofen every 6 hours. Follow-up visits were performed 2–4 weeks and 6–12 months after surgery to assess position and size of the testes, as well as assess the umbilicus.

Results

A total of 17 patients were identified. Median age was 11 months (range 3–43). Sixteen patients underwent primary orchidopexy, including two bilateral procedures (Fig. 1a) and five primary FS procedures. One patient underwent a staged FS orchidopexy, with the LESS technique utilized during the second stage. Of the 15 unilateral procedures, 6 were right and 9 were left sided. Median laparoscopic dissection time for each testis was 35 minutes (range 22–40). Median total operative time was 55 minutes (range 42–60) for the unilateral procedures. The bilateral procedures were performed in 70 and 75 minutes. There was no blood loss or intraoperative complications. No accessory incisions were used.

OPEN IN VIEWER

FIG. 1.

(a) Immediate postoperative appearance in a patient with bilateral orchidopexy. (b) Immediate postoperative appearance of umbilical incision.

All patients returned for follow-up visits. Patients were followed for 12 months and discharged. No patients were lost to follow-up. All testes were noted to be in the scrotum without testicular atrophy. The umbilical scar was hidden, due to the use of the natural umbilical scar that results from desiccation of the umbilical cord stump. There were no wound infections or signs of umbilical hernia.

The hospital cost for the Olympus TriPort is $395. A 5 mm Covidien Step^™ trocar was used for the umbilical trocar during initial diagnostic laparoscopy, when the presence of an intra-abdominal testis was unknown. The hospital cost for a 5 mm trocar is $92.11. If three 5 mm trocars are used for a standard LO, the hospital cost for the trocars would be $276.33 per procedure, compared to $487.11 for a LESS orchidopexy. The hospital cost for a 2/3 mm trocar is $53.89. If a 5 mm trocar and two 2/3 mm trocars are used, the hospital cost would be $238.11. The initial cost for our hospital to purchase two FTLs was $41,721.60. A required video system was $17,712.00, and two sterilization trays were $3,841.66. Increased utilization of the FTL for any laparoscopic procedure decreases the cost per case.

Discussion

LO is a well-established procedure for the treatment of intra-abdominal testes. Recently, LESS orchidopexy has been reported describing various techniques. ^{8 –11} At our institution, LESS surgery has been recently utilized for pediatric urological procedures, including orchidopexy. To the best of our knowledge, we report the first and largest series utilizing a MCSP and FTL for LESS orchidopexy in the pediatric population.

The technique is more challenging than a standard LO. The single incision limits the range of motion and triangulation of traditional laparoscopic surgery. Standard straight instruments were used in our procedures. Curved instruments may potentially provide a mechanical advantage, providing some element of triangulation, over standard instruments. It was noted that one obstacle faced during the procedure was the confined space of movement outside of the patient, despite the benefit of a FTL. Longer instruments were helpful to gain a little more space to manipulate the instrument handles, than shorter laparoscopic instruments that are often used for infants and small children. Curved instruments may potentially minimize external instrument collisions as well. Magnetically anchored and guided camera systems may also reduce external collisions by reducing the number of instruments being manipulated in the port. ¹²

The operative time for LESS orchidopexy was no longer than standard LO in this report. However, the experience with standard laparoscopic procedures far exceeds our experience with LESS. The surgeon is experienced in advanced laparoscopic procedures, which may have shortened the learning curve and/or operative times. The laparoscopic time was shorter in our series compared to other previous reports. ^{9 –11} Raju et al. reported a technique using standard trocars through a single umbilical incision with an intra-abdominal time of 126 minutes. ⁹ Utilization of the MCSP may have contributed to a shorter operative time in our experience. The MCSP may have also provided a larger working space by maintaining pneumoperitoneum due to a better seal from the device, without gas leakage around multiple trocars through a single skin incision. In our limited experience, loss of pneumoperitoneum can severely limit the ability to proceed due to loss of visualization, which occurred occasionally with the device. The MCSP can also provide a better functional working space compared to standard trocars, which extend into the abdomen and limit the space before an instrument can be utilized.

de Lima et al. reported using rigid laparoscopes for their LESS orchidopexy with an operative time ranging from 70 to 95 minutes. ¹⁰ FTLs, MCSPs, and curved instruments were not available for use in their country at the time of their reported experience. Utilizing the FTL may have provided a technical advantage reducing operative time by enabling different options for visualization that cannot be obtained with a rigid laparoscope, especially through the same entry site for instruments. An additional benefit of the FTL is the ability to move the shaft of the laparoscope away from the instruments. This reduced external collisions in the limited range of motion outside of the patient for standard laparoscopic instruments through a single entry site, yet maintained an adequate view of the surgical site with the FTL. This also has the potential to reduce operative time.

All of the procedures were completed without accessory incisions for instrumentation. There were no intraoperative or early postoperative complications in our series. Furthermore, this procedure achieved a hidden umbilical incision resulting in an almost scarless procedure (Fig. 1b). No trocar was used for the delivery of the testis into the scrotum as reported by others, avoiding an added cost. ^9,10 No postoperative narcotics were needed in our early experience with this technique.

Limitations of this study include its retrospective nature, single surgeon experience, small sample size, and lack of a comparison group. No objective assessment of postoperative cosmesis was performed. Further study is warranted evaluating morbidity, such as postoperative pain, ergonomics, costs, and cosmesis, compared to other techniques for surgical management of intra-abdominal testes.

Conclusions

Our initial experience with this technique was favorable with excellent outcomes. LESS orchidopexy is facilitated with a MCSP and FTL.